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Wilson and colleagues are to be commended for their excellent work in exploring mental illnesses and desire for death in patients receiving palliative care with malignancy. [1] The piece thoughtfully explores the prevalence of depression, anxiety and mood disorders and the association between these diagnoses and a standardized quantification of the patient's desire for death. In all, the authors found that 30.5% of participants e...

Wilson and colleagues are to be commended for their excellent work in exploring mental illnesses and desire for death in patients receiving palliative care with malignancy. [1] The piece thoughtfully explores the prevalence of depression, anxiety and mood disorders and the association between these diagnoses and a standardized quantification of the patient's desire for death. In all, the authors found that 30.5% of participants experienced transient desire for death, and 12.2% of patients with a more pervasive and genuine wish that was described as "moderate", "strong", "severe", or "extreme."
Several aspects of these findings warrant comment. First, the authors report that it appears that those without a serious desire for death and without mental disorder seemed to be "coping well and achieving optimal palliative care outcomes." While I agree with this assessment and hope that the palliative care intervention contributed, in part, to this lesser distress, it remains unclear if the palliative care is helping in the situation, or if this results from coincidence or participation bias. Conversely, those participants with serious desire for death and current mental illness were noted to be experiencing a more difficult course despite palliative care intervention. This begs the question as to how such concerns were addressed aggressively by the interdisciplinary palliative care team yet still persisted.
Perhaps most critical are the findings that relate to the possibility of desire for death, mental disorder, and request for or completion of physician-assisted death in this population. The authors report data from the Netherlands where patients with depression and underlying psychological disorders, and concomitant terminal illness, are more likely to have their request for physician assisted death denied (citing 3 studies). [1] However, it is difficult to determine if practices have changed substantially over the past two years since their report was completed and now published in print. Furthermore, it can be challenging to tease out the research facts and findings at a population level, and extrapolate this information to the individual case level.
Indeed, in other recent analysis by Kim, De Vries and Peteet published electronically late in 2015, the authors reviewed 66 cases in the Netherlands where psychiatric conditions led to request and granting of euthanasia or assisted death for patients with purely psychiatric conditions [2] and not concurrent malignancy as was the case in Wilson and colleagues' paper. In Emanuel and colleagues' review of characteristics of euthanasia and physician-assisted suicide cases across the United States (in jurisdictions where legal), the Netherlands and Belgium, it was notable that 4.6% of all deaths in Belgium results from euthanasia, including 12% of those cases fitting into the "mental" health indication profile. [3]
Although euthanasia is not legal in the United States, discussion about physician assisted suicide are ongoing in many states, as well as in Canada. Discussions about the practice of physician assisted death are often extrapolated from the European experience, which frequently serves as the basis for policy discussion among North American clinicians and lawmakers. Credible media reports of euthanasia for "unbearable psychological suffering" have been openly reported in cases in Belgium [4] and Dignitas has reported provision of aid-in-dying to patients with underlying mental illness in Switzerland. [5] The data in aggregate from Kim and colleagues, and Emanuel and colleagues, suggest that these cases in the media are not necessarily rare or sporadic, but may be part of a small but regular population who seek hastened death and have their requests granted. While Wilson and colleagues suggest the possibility of "hesitation when [euthanasia or physician-assisted suicide are] used to relieve their expression of despair", the data in aggregate may suggest otherwise, and that heightened scrutiny of hastened death for individuals with concurrent mental disorders may not actually be the case.
References:
1. Wilson KG, Dalgleis TL, Chochinov HM et al. Mental disorders and the desire for death in patients receiving palliative care for cancer. BMJ Support Palliat Care 2016;6:170-177 doi:10.1136/bmjspcare-2013-000604
2. Kim SYH, De Vries RG, Peteet JR. Euthanasia and Assisted Suicide of Patients With Psychiatric Disorders in the Netherlands 2011 to 2014. JAMA Psychiatry. 2016;73:362-368.
3. Emanuel EJ, Onwuteaka-Philipsen BD, Urwin JW, Cohen J. Attitudes and Practices of Euthanasia and Physician-Assisted Suicide in the United States, Canada, and Europe. JAMA. 2016;316:79-90.
4. Euthanasia twins 'had nothing to live for'. The Telegraph. Available at http://www.telegraph.co.uk/news/worldnews/europe/belgium/9801251/Euthanasia-twins-had-nothing-to-live-for.html Accessed July 14, 2016
5. Suicide-Clinic Entrepreneur: Depressed? 'We Never Say No'. Available at http://www.wnd.com/2006/04/35738/#! Accessed July 14, 2016